The Very Worst Workers Comp Medical Only Claims
Recently, I posted on the pitfalls of Workers Comp medical only claims. That article is here. The worst medical only claims nightmare results from claims festering – or an unknown claim that sits with undiscovered liability.
There is a very small window of time where a claim can be investigated – regardless of whether it is a medical only or a lost time Workers Comp claim. The three-point contact (Employer, Employee, and Medical Provider) must be made within 24 hours. This allows for a timely and proper accept/deny decision.
Medical benefits are paid timely, but the claim is becoming more serious without any monitoring. The medical bill expense may not necessarily signal any problems if the injured employee keeps working and only has medical office visit and prescription expenses. The claims staff usually does not contact the injured employee in these cases.
Who monitors these claims? The answer is usually no one. The medical bills are processed and the claims just keep growing and growing with no intervention.
Some systems automatically monitor and flag the lost time adjuster that a med-only file has reached a certain reserve limit; days without closing, or other variables that indicate a much more serious claim that when originally opened at the start of the claim.
Yes, there is a med-only adjuster than may alert their supervisors on a few of these types of claims. They are usually too overloaded with volume to read every medical report.
Med-Only Claims Adjuster Is Key
A talented Medical Only claims adjuster spots this type of claim early in the process. Do not ever think these adjusters are not that important. Heading off a very serious case of claims festering(c) saves massive claim payouts in the future.
The ability to spot these claims is an art unto itself. How does an employer monitor these claims? I will cover that next time.
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